Demand for services
Increasing demand for children and young people’s services
Nearly all respondents (97%) said that the current level of demand for children and young people’s services has increased since the pandemic. The national data shows that trusts across the NHS are providing care to an increasing number of children and young people but are still struggling to meet rising demand. For instance, 5.3 million children and young people were in contact with mental health services in 2023/24 - up by 8.1% compared to 2022/23 and 25.7% compared to 2021/22.
Only 16% of respondents said they were meeting current demand for children and young people’s services. When broken down by sector, ambulance trusts were more positive about their ability to meet demand, with 50% (four respondents from ambulance trusts) saying they are doing this. Looking to the next 12-18 months, 75% of respondents said they would be unable to meet anticipated levels of demand. These findings support the national data outlined above, and are consistent across trusts delivering acute, mental health and community services, although respondents from ambulance trusts were more likely to say that demand had stayed the same compared to pre-pandemic levels.
Trust leaders were similarly concerned by their wider partners’ ability (schools and colleges, the voluntary sector, social care and local authorities) to meet demand for children and young people’s services, with 89% saying that their partners were unable to do this. Capacity across both health and wider public services is central to tackling the challenges outlined in this report.
Why demand cannot currently be met
The most common answers to the question ‘what are the top three reasons that demand for children and young people’s services is not being met at your trust?’ were: increased acuity and complexity of patients and service users (58%), insufficient services commissioned (39%) and long term impact on demand caused by the Covid-19 pandemic (30%). Trust leaders report that the increased acuity and complexity of children and young people has several causes. All of the following are viewed as having had an impact, particularly on children and young people presenting to mental health services: the long-term effects of the Covid-19 pandemic, including the impact of lockdowns on health and wellbeing, in-person education, and contact with public services; cost of living pressures and inequalities; and wider societal shifts such as access to smartphones and social media. These factors are also impacting on acute trusts, with leaders reporting increasing numbers of children and young people with eating disorders presenting in emergency departments and being admitted to adult hospital beds. These are not the most appropriate settings for children and young people to receive treatment, but they are often viewed as a ‘place of safety’ while individuals wait for a specialist care.
Staff shortages and insufficient funding are also contributing to challenges meeting demand for children and young people’s services. Only 17% of respondents felt their trust had the right number and mix of staff in place to deliver timely, high quality care. Likewise, only 14% said this was the case for capital funding, and 15% for revenue funding.
Recommendation:
NHSE and government should require ICSs to give sufficient prioritisation to children and young people’s services, and ICSs should protect local capital and revenue funding to help to address the challenges outlined in this report.
Explaining in more detail, several respondents said that growing recognition and understanding of neurodevelopmental disorders, including attention deficit hyperactivity disorder (ADHD) and autism, was leading to increasing referrals, diagnoses and demand for services. This had the greatest impact on trusts providing mental health and community services.
"Since 1 April 23 to 1st April 24 there is an 83% increase in referrals onto the ADHD pre-diagnostic pathway and 85% increase for ASD within the same timescale."
"41% increase in referrals to CAMHS in 2022/23 compared to 2019/20; 127% increase in referrals to eating disorders in 2022/23 compared to 2019/20; ASD/ADHD diagnostic pathway (inc. continued challenges with ADHD meds shortage) – 103% increase in waiting list size over previous year (1034 March 2023 vs. 2100 March 2024)."
Gaps between paediatric and adult services are also contributing to challenges meeting demand, and can leave young people struggling to access care because there is an age cut off for a service or waiting list, or because they transition between children and adult services. Four out of five respondents (80%) reported concern about gaps in service delivery between paediatric and adult services. This is despite the commitment in the NHS Long Term Plan (NHS England, 2023) to move to a ‘0-25 years’ service by 2028. Respondents said this often occurred in mental health services and neurology or neurodevelopmental services, and had the greatest impact when health needs were most complex. Considering growing demand in these service areas, there is a risk that increasing numbers of children will face very long waits and struggle to access care due to gaps between paediatric and adult services.
Recommendation:
NHSE should undertake a full review of transitions between paediatric and adult services to understand where there are common gaps. This would build one existing national work around delivering a 0-25 service, and inform the development of nationally led policy and guidance to support providers and systems to tackle this.
Impacts of demand not being met
Trust leaders are deeply concerned by the impact that difficulty accessing services is having on children and young people. Over two thirds of respondents (69%) said children were being harmed by long waits for services, while 71% agreed that long waits at their trust were contributing to health inequalities.
In their comments, respondents highlighted links between deprivation, long waiting times to access services and worse outcomes. Our report ‘Reducing health inequalities faced by children and young people’ (NHS Providers, 2023) outlines a suggested set of actions trusts could take to tackle health inequalities experienced by children and young people. These include embedding NHS England’s Core20PLUS5 (NHS England, 2021) framework for children and young people, and seeking to involve children and young people more in the design and delivery of services.
"Long waiting times for children from deprived backgrounds or recent immigrants mean that they are sicker when they finally get to us. Also seeing an increased level of mental illness in our patients."
"[The trust] serves a population in which c. 67% of children and young people live in absolute or relative poverty; this means significantly higher prevalence of issues with oral health, mental health and driving exceptionally high demand, which cannot be adequately met - and therefore widening inequalities."Strategy director, acute specialist trust
Respondents were also concerned about the impact the challenges outlined are having on staff delivering these services. Indeed, 86% of respondents said they were extremely or moderately concerned about the impact that challenges providing care for children and young people is having on staff morale. These impacts on staff morale have the potential to make recruitment and retention of staff more difficult, exacerbating existing workforce pressures and challenges meeting demand. The NHS Long Term Workforce Plan (LTWP) (NHS England, 2023) outlines opportunities to increase the number of staff delivering children and young people’s services, including by increasing the health visiting workforce by 2031/32. However, the workforce pressures in children and young people’s services require further focus, both within the NHS and outside the remit of the plan, in social care and the voluntary sector.
Recommendation:
To support and embed the work that frontline trusts are pursuing, government should commit to fully funding and delivering the LTWP and, at the review taking place in summer 2025, update the plan so there is a stronger and clearer focus on prevention and early intervention.
Waiting lists and waiting times
Compared to before the pandemic, respondents said waiting times for children and young people to access an initial assessment have increased (86% said significantly or moderately). Likewise, 88% of respondents reported that waiting times for follow up treatment had increased compared to pre-pandemic.
When asked about the services they were most concerned about, the highest number of mentions referenced neurodevelopmental services like autism, ADHD and community paediatrics. Many trusts also referenced speech and language therapy, eating disorder services and dental services. This aligns with existing evidence on demand for and access to these services. National data shows a rising number of children are struggling to access dental services (Office for Health Improvement and Disparities, 2024) while reports by the Children’s Commissioner (Children’s Commissioner, 2024b) and the Royal College of Speech and Language Therapists (Royal College of Speech and Language Therapists, 2022) highlight growing demand for mental health and speech and language therapy.
Respondents shared examples of their waiting lists and waiting times for children and young people’s services, revealing significant increases in both. This is particularly the case for neurodevelopmental pathways, where there are examples of 300% increases in waiting lists and average waiting times of three years.
Trust leaders said delays to accessing services would have a significant impact on children and young people, especially to their personal development, school readiness and educational attainment. Not only does this contribute to anxiety and stress for individuals and their families, but it is likely to have a longer term impact on the life chances of these children and young people. Long waits were also viewed as diminishing the scope for early intervention and contributing to increasing complexity and acuity later, when treatment is accessed.
"300% increase in children and young people awaiting neurodevelopment assessments from September 2019 to September 2024."
"The waiting list for children's continence is now 50% higher than it was in June 2021. There are c. 1000 children and young people on our speech and language therapy waiting list, which pre-pandemic was c. 300. Pre-pandemic the majority waiting for speech and language therapy were assessed within 13 weeks. In April '24, 62% wait more than 13 weeks, with 47% waiting over 18 weeks."
"Children's spinal surgery waiting times were below 52 weeks in 2019. In comparison we now have a maximum wait time >104 weeks"
Recommendation:
Using the insights from frontline services, NHSE should review children and young people’s services facing the most significant issues meeting demand, for instance autism and ADHD, with a view to setting national strategy to improve access, experiences and outcomes. This is likely to build on and bring together existing national work, for instance NHSE’s new ADHD taskforce announced in March 2024